Provider Demographics
NPI:1447267679
Name:KHAN, SHUJAATALI M (MD)
Entity type:Individual
Prefix:
First Name:SHUJAATALI
Middle Name:M
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 JOHN KISSINGER DR
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1648
Practice Address - Country:US
Practice Address - Phone:260-569-2221
Practice Address - Fax:260-569-2305
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053702A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200359310Medicaid
IN200359310Medicaid
941160QQQQMedicare ID - Type Unspecified